Phonosurgery refers to surgical procedures aimed at improving or restoring voice quality. It is broadly classified into two main types: Primary Phonosurgery and Secondary Phonosurgery. This field also includes Phonetosurgery or Phonetic Surgery, which involves surgical interventions on the vocal tract, such as uvulopalatopharyngoplasty (UPPP), cleft lip repair, and adenoidectomy. Laryngeal surgeries, used for diagnosing and treating both benign and malignant conditions, have increasingly focused on achieving better vocal outcomes. Various techniques are employed to assess voice disorders, including Videolaryngoscopy, Stroboscopy, Laryngeal Electromyography, and acoustic and perceptual analysis. Factors such as smoking, voice misuse, occupation, reflux, hypothyroidism, psychological health, and medical treatments play a significant role in evaluating these disorders. Phonosurgery employs different surgical methods and instruments tailored to address specific vocal cord conditions and lesions.
Microlaryngoscopy, often performed with lasers and microdebriders, is commonly used for benign vocal cord conditions. Vocal fold injections with materials like Teflon, fat, collagen, and silicon are used to treat conditions such as vocal fold paralysis, nodules, polyps, and cysts. Laryngeal framework surgeries, including medialization thyroplasty and arytenoid adduction, aim to improve vocal cord positioning and function. Woodman’s procedure and Isshiki type II thyroplasty address structural and functional vocal issues, while laser cordectomy is used for laryngeal cancer treatment. Advanced techniques such as the Kashima method, Type III and IV thyroplasty, and anterior cartilage modifications allow for adjustments in vocal pitch and quality. Reinnervation and reconstructive surgeries, including thyroplasty with muscle flaps, aim to restore nerve function or repair damaged vocal folds, offering improved voice outcomes for patients with complex disorders.
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SLIDES OUTLINE
PHONOSURGERY
Introduction
Any surgery designed primarily for the improvement or restoration of the voice.
Types:-
1. Primary Phonosurgery
2. Secondary Phonosurgery
Phonetosurgery/Phonetic surgery – surgery of vocal tract e.g. UPPP, cleft lip repair, adenoidectomy
Introduction
Introduction
Introduction
Introduction
Introduction
Laryngeal surgery:-
- Dx & removal of malignant disease
Benign disease & its effect on voice was given less importance
Last few decades, awareness & emphasis on vocal results
Assess the voice disorder
1. Videolaryngoscopy
2. Stroboscopy – assess mucosal wave of vocal fold
3. Laryngeal electromyography
- aid in localization of lesions in the vagus
nerve/SLN/RLN
- signs of reinnervation in a paralyzed vocal cord
- CA joint fixation vs nerve damage
Assess the voice disorder
4. Acoustic measures
•Fundamental frequency—Mean F0, SD F0, Min F0, Max F0.
•Frequency perturbation—Jitter (%).
•Amplitude perturbation—Shimmer (dB).
•Harmonic-to-Noise Ratio—HNR (harmonic-to-noise ratio).
•Voice Irregularity—DVB (degree of voice breaks).
5. Electroglottography
6. Aerodynamic measures
7. Perceptual Analysis
•Hirano: GRBAS (grade, rough, breathy, asthenic, strained) scale.
Evaluate precipitating/aggravating factors:
Smoking
Voice misuse/abuse
Occupation e. g. Singer/Teacher
Extra-oesophageal reflux
Hypothyroidism
Psychological state
Medical & supportive treatment when appropriate
Vocal hygiene, life style & dietary advice
Voice therapy
Medication e.g. PPI
Address psychological issues
Microlaryngoscopy
Bozzini (1807) :-
first to visualize larynx
described 1st IL for surgery on VF
Manuel Garcia (1855) :-
credited for 1st description of mirror IL
(dental mirror)
IL scopic surgery – beginning of 19th century
Open surgery for biopsy and treatment
Microlaryngoscopy
Horace Green (1852):-
1st direct laryngeal surgical case
Albrecht (1954):-
Introduced concept of phonosurgery
Gynecologic colposcope for microlaryngoscopy
Scalo (1960 ):-
1st report describing magnification and stereoscopic visualization
Microlaryngoscopy
Jako (1962) :-
Reports on microlaryngeal surgery
GA with paralysis
Jako (1970s):-
Introduces the laser coupled to the operating microscope
Phonosurgery: Current Concepts
1. Preservation of the vocal fold’s layered microstructure results in optimal post-op voice production
2. Elevated vector-suspension laryngoscopy is essential to visualization
3. Haemostasis and exposure are keys to good outcomes
4. Instrument selection enables the surgeon
5. Use of the laser is not the same as cold instrument techniques
Microlaryngoscopy
Superficial layer oscillate on phonation over the underlying structure (cover/ body theory)
Benign diseases – mucosal layer or superficial part of the lamina propria
Surgery:-
Stay superficial
Avoid trauma to vocal ligament – scarring
Limited mucosal excision
Microlaryngoscopic surgery
Proper diagnosis
Patient selection
Other issues addressed
Proper instruments
Counseling & Consent
High quality voice recording
Need for F/U & speech therapy
Microlaryngeal surgery
Advantages (over direct laryngoscopy):
Binocular vision
Magnification
Better illumination
Ability to use bimanual instrumention
Ability to use CO2 laser
Microlaryngeal surgery
Instruments:-
Dissecting instruments
Laser
Laryngeal microdebrider
Laser & dissecting instruments have similar results in experienced hands
Personal preferences
Availability/ expertise
Microlaryngeal surgery
Laser:
Preferred in
1. Vascular lesion
2. Lesions that bleed on removal e.g. papillomatosis or granulomas
3. Removal of cartilage
4. Excising large areas of tissue
Risks:
Risk of infection – papillomatosis
Seeding down tracheobronchial tree – jet ventilation
GA
ET tube/ Jet ventilation
Respect vocal fold microanatomy
Voice rest:-
Absolute – 48 hrs
Relative – 10 days
Nodules
Soft nodules – speech therapy
Hard nodule – surgery + speech therapy
Vocal polyp
Reinke’s oedema
Intracordal cyst
Mucous retention cyst
Epidermoid submucosal cyst
Microflap technique
Vocal Fold Vascular lesion
Ectasia
Varicosity
Hematoma
Vocal fold web
Arytenoid granuloma
Papillomas
Single - CO 2 Laser excision – at base
Multiple – hydrodissection – submucosal saline /adrenaline infusion
- en – bloc excision of mucosa
All specific Laser precautions + specialized laser masks
Laryngeal microdebrider
Adjuvant alpha interferon , ribavarin , cyclo-oxeygenase inhibitors, cidovir
Vocal sulcus
Physiological or pseudosulcus
Sulcus vocalis
Sulcus vergeture
Injection of collagen or fat
Excising
Vocal Fold injections
Brunnings (1911)
First to describe injection of vocal folds
Injected paraffin via direct laryngoscopic approach ↓ L. A.
Arnold (1962)
Popularized the technique
Introduction of Teflon
Vocal Fold injections
Materials used
Paraffin (Brunings, 1911)
Teflon (Arnold, 1962)
Silicon (Fukuda, 1970)
Glycerine/gelfoam paste (Schramm et al., 1978)
Bovine collagen (Ford and Bless, 1986)
Autologous Fat (Brandenburg et al., 1992)
Autologous collagen (Ford et al, 1995)
Autologous and alloplastic materials.
Transoral or percutaneous approaches
3/2012 Cochrane review found insufficient high quality evidence to support the effectiveness of any particular injectable material.
Indications:
Correction of glottic incompetence due to:
Unilateral vocal fold paralysis.
Sulcus or after surgery or trauma.
(Hirano et al, 1989)
Contraindication:
Mobile or potentionally mobile VF.
CA joint fixation.
Post-hemilaryngectomy.
Inflammatory diseases and medical conditions
Ideal bio- injectable material
Should be biologically well tolerated, biocompatible.
Easily handled and easily injected.
Resistant to resorption after injection.
Should not interfere with mucosal vibration.
Should be easily reversible (explantable)
Should not migrate from the site of injection.
Lack of donor-site morbidity.
Operative techniques
Direct laryngoscopic method:- GA
Operative techniques
L. A.-
-Direct laryngoscopic
-Indirect laryngoscopic
-Transcutaneous route
Cricothyroid membrane
Thyroid cartilage
Teflon
Teflon + 50% glycerine
Glycerine absorbed in few weeks
Inflammatory reaction → encapsulation of remaining Teflon (granuloma)
Final size :- unpredictable
Immediate good result may deteriorate
Good for
U/L VC paralysis
Short life expectancy
Teflon
Problems:
1. Too superficial:-erosion of overlying mucosa with granuloma on surface
2. Impair VF vibration
3. Migration
4. Poor long term results
5. overdose → apnoea
6. Irreversible
Fat
Easily harvested
Readily available
No FB reaction
Temporary:- 30-50% absorbed within 1st month
? overcorrection
Requires injection deep into VF
Good immediate voice quality
Glycerine
Temporary material/ completely reversible
Absorbed within first 2-6 months
May be combined with laryngeal electromyography in temporary paralysis (to look for reinnervation)
Deep within muscle of VF
Collagen
Natural constituent of lamina propria of VF
Ford et al. popularized its use in larynx
Becomes incorporated & assimilated by new host tissue
Bovine collagen
(glutaraldehyde addition – better stability, ↓hypersensitivity)
Preop skin testing
Injected into vocal ligament
Challenging procedure
Irregularity in mode of absorption & replacement
Silicon
Silicon gel
Inflammatory reaction → fibrous capsule
Deep in body of VF
Popular in Europe
Immediate results
L. A.
normal anatomical position
Feedback from pt with phonation
Reversible e. g. glycerine
Irreversible e.g. Teflon
All except collagen are straight forward to inject
Complications
All:
Over-injection
Under-injection
Airway compromise
Silicon & Teflon
Misplacement
Migration
Teflon
Granuloma formation
Laryngeal Framework Surgery
Payr (1915):- First medialisation procedure
Meurman (1952):- implanted free rib grafts beneath the inner thyroid perichondrium.
Opheim (1955):- placed thyroid cartilage medial to inner perichondrium
Montgomery (1966) :- repositioned the arytenoid – fixed it to the cricoid cartilage with pin.
Isshiki et al (1975)
rectangular window at the level of VF
First to use alloplastic material (silastic)
L. A. – pt feedback
Allows modification of:-
Size of glottic aperture
Plane of closure of vocal folds
Length of vocal folds
Advantages:-
Maintains laryngeal dynamics
No invasion of VF
No alteration of VF mass or stiffness
Patient selection
U/L vocal cord paralysis
Wait 12 months for idiopathic cases
Early intervention:-
Severe aspiration
Vocal needs of patient : eg singer
Alternative:
Repeated glycerine injection
Laryngeal EMG monitoring
LFS ( ELS 2001- Classification)
1) Approximation laryngoplasty
Medialisation thyroplasty (Isshiki type I thyroplasty)
Arytenoid adduction (rotation/ fixation)
2) Expansion laryngoplasty
Lateralisation thyroplasty (Isshiki type II a or b)
Vocal fold abduction(suture/resection technique)
3) Relaxation laryngoplasty
Shortening thyroplasty
Lateral approach (Isshiki type III )
Medial approach
4) Tensioning laryngoplasty
Cricothyroid approximation (Isshiki type IVa)
Elongation thyroplasty
Lateral approach (Isshiki type IVb)
Medial approach
Isshiki’s functional classification
Type I - Medialization.
Type II - Lateralization.
Type III - Relaxation (shortening).
Type IV - Stretching (lengthening).
Type I thyroplasty
Medialisation of VC by its inward displacement with an implant placed through a window in the thyroid cartilage
Indications:-
U/L Vocal cord palsy
U/L or B/L bowed vocal cord caused by aging
Sulcus vocalis
Soft tissue defects in vocal fold as a result of previous surgery
U/L vocal cord palsy (n=827)
Surgery (46%)
Idiopathic (18%)
Malignancy (13%)
Others (23%) (Trauma, intubation, CNS, infection etc.)
Surgery
Thyroid &/or parathyroid(33%)
Other (67%) –ant cervical spine, carotid endarterectomy, cardiac surgery etc.
(Rosenthal et al, 2007)
TVFMI (Titanium vocal fold medialization implant )
Advantages:
Permanent, but surgically reversible
No need to remove implant if vocal function returns
Excellent at closing anterior gap
Disadvantages:
More invasive
Poor closure of posterior glottic gap
Complications
Overall: 3%
•Incomplete glottic closure: 10-15% of patients
•Airway obstruction requiring intervention (2.2%)
•Implant migration or extrusion
•Maintain inner perichrondrium
•Avoid undermining paraglottic space anterior to window
•Valsalva to assess for leaks prior to placement of implant
•Suture implant
•Penetration of the endolaryngeal mucosa
•Wound infection
•Chondritis
Poor results:-
Patient selection
Thyroid compression test –
Posterior glottic chink
Vertical levels of vocal cords
Problems
Too small prosthesis
Incorrect placement (false cord)
Modifications:-
Arytenoid adduction
Arytenoid fixation & cricothyroid subluxation
Useful in Large posterior gap
Paralysed cord at different levels
Tension & bulk to the paralysed vocal cord
Arytenoid adduction technique
Atrophic muscle
Only 9% of total TVC palsy cases
Other causes: post RT, high vagal neuroma excised
Laryngeal EMG helps diagnosis
Problems:- easy to perforate laryngeal mucosa while elevating inner perichondrium
Implant extrusion inward – sternothyroid muscle
Lateralisation
Laser cordectomy/arytenoidectomy
Cordopexy/ suture lateralisation
Woodman’s procedure
Isshiki type II thyroplasty
Laser cordectomy/arytenoidectomy
Co2 laser resection VC/ arytenoids
Laser 4 - 10 W superpulse mode , spot size not more than 0.8 mm
Traditional :
- wedge – post half TVC + medial arytenoid
- Tapering resection anteriorly
- Bulk resection – post resp area
Kashima method : Transverse laser cordotomy
ant to vocal process .
Medial arytenoidectomy :
Mucosa – sup / medial portion arytenoid – lasered
Arytenoid removal post to vocal process .
Prevent going below arytenoid level .
Type III – Relaxation (shortening)
Aimed at lowering the vocal pitch.
The VF is relaxed by A-P shortening of the thyroid ala.
Indications:
Males with high pitch voice, resistant to voice therapy.
Stiff VF with high pitched breathy voice.
Spastic dysphonia.
Type IV – Stretching (Lengthening)
CT approximation to elevate pitch .
Indications:
Bowed FV.
Androphonias.
Techniques to elevate the pitch
Inferiorly based anterior cartilage flap.
(LeJeune et al, 1983)
Superiorly based cartilage flap.
(Tucker et al , 1985)
Anterior commissure advancement.
(LeJeune et al, 1987)
Reinnervation
RLN anastomosis – described by Horsley (1909)
Crumley (1985)
Popularized ansa cervicalis to RLN anastomosis
Reinnervating the PCA muscle
Nerve anastomosis. Phrenic nerve /ansa cervicalis.
Phrenic nerve implantation. (Crumley et al , 1983)
Neuromuscular pedicle Transplantation.
(Tucker et al , 1977)
Reinnervation
Reinnervating the TA muscle
Ansa cervicalis to RLN anastomosis.
(Crumley et al , 1991)
Neuromuscular pedicle Transplantation.
(Crumley et al, 1985)
Reinnervation
Hypoglossal to recurrent laryngeal nerve
Re-innervated muscle takes on characteristics of its supplying nerve
Laryngeal muscle
Controlled to contract at specific time
High fast contractile fibres
Ansa cervicalis also lacks other components of RLN-parasympathetic fibres, afferent sympathetic
Reinnervation
Crossed nerve grafts or wire conduction prosthesis from one muscle paralyzed counterpart (under research)
Reconstructive phonosurgery
Reconstruct the resected VF after partial or hemilaryngectomy
Hirano et al. (1976) - sternothyroid muscle
Friedman et al. (1985)
Contralateral superior thyroid cornu.
El Kahky et al. (1989)
Ipsilateral pyriform sinus mucosal flap with intact superior laryngeal neurovascular bundle.
Reconstructive phonosurgery
After TL
TEP + Prosthesis
